IAM Treasurer

Price:

Free

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phone:* Phone is Required

Company: Company is not valid

Title: Title is not valid

Website: Website is not valid

Atty # / Mediator #: Atty # / Mediator # is not valid

Please list the schools of higher education from which you've graduated, along with years of attendance and degree:* Please list the schools of higher education from which you've graduated, along with years of attendance and degree is Required

How many hours of mediation training have you received?:* How many hours of mediation training have you received? is Required

Less Than 50 50 - 75 Hours 75 - 100 Hours More than 100 hours

List the mediation courses you've completed and indicated whether or not they've been certified by the ICCLE Commission. If you checked 'More than 100 hours' above, simply enter 'More than 100 hours' below.:* List the mediation courses you've completed and indicated whether or not they've been certified by the ICCLE Commission. If you checked 'More than 100 hours' above, simply enter 'More than 100 hours' below. is Required

Your Profession (Lawyer, Mental Health Professional, Social Worker, etc.):* Your Profession (Lawyer, Mental Health Professional, Social Worker, etc.) is Required

Attorney # / Indiana Registry Mediator #: Attorney # / Indiana Registry Mediator # is not valid

I accept mediation cases in the following categories:* I accept mediation cases in the following categories is Required

Civil Mediation Domestic Mediation Reconciliation Other (As Described in Profile)

Description of your practice and experience for your profile: Description of your practice and experience for your profile is not valid

I serve Northwest Indiana

I serve the South Bend / Elkhart area

I serve the Fort Wayne area

I serve the Kokomo / Logansport area

I serve the Lafayette area

I serve the Indianapolis metro area

I serve the Muncie / Richmond area

I serve the Columbus & Southeast Indiana area

I serve the Bloomington / Bedford area

I serve the Terre Haute area

I serve the Evansville area

I serve the South Central Indiana (Louisville Metro) area

Mediator Liability Insurance Carrier:* Mediator Liability Insurance Carrier is Required

Policy or Endorsement #:* Policy or Endorsement # is Required

Single Claim / Aggregate Amount (Minimum amount $100,000 / $300,000):* Single Claim / Aggregate Amount (Minimum amount $100,000 / $300,000) is Required

Policy Expiration Date:* Policy Expiration Date is Required

I have read and agree to the terms of the Mediator Referral Agreement*

I serve the following areas:*

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Medium" or stronger

No val

Please fix the errors above

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